11/13/24, 7\:20 PM Guide | Horizontal mattress suture

Horizontal mattress suture

Table of contents

Introduction

This guide demonstrates how to perform a horizontal mattress suture, including step-by-step images and a video
demonstration of the procedure.
Horizontal mattress sutures are particularly useful in wounds under tension. They also help to evert wound edges in situations
where skin is prone to naturally inverting into the wound. The horizontal mattress suture is a square-shaped suture with the
knot lying parallel to the wound.

Equipment

Needle holder (a.k.a. Driver)

Needle holders should be held with your dominant hand.
Put your thumb through one handle and place your ring
they feel you have greater dexterity and range of movement (this is referred to as "palming").
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Needle holder closed

Toothed forceps (a.k.a. Pickups)

Hold the forceps with your non-dominant hand in the same way you would hold a pen.
Be gentle when using toothed forceps to manipulate skin, do not grip it too tightly or you may damage the wound's edges.
Hold the forceps with your non-dominant hand in the same way you would hold a pen

Scissors

Scissors are used for cutting sutures.
Position your index
Rest the blades on your index
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Use scissors to cut sutures

Suture

surgeon's preference.
Di
Please see our separate guide on suture materials for more information.

Principles of wound management

All wounds should have local anaesthetic in
the lip as this may distort the normal anatomy.
Following this, they should be thoroughly washed and the wound bed should be examined for internal damage. Patients
should be up to date with their tetanus immunisation and contaminated wounds warrant a course of an antibiotic such as co-
amoxiclav or a suitable alternative if allergic.
X-rays should be performed if there is suspicion of a fracture or foreign body.
Wound edges should be debrided if the wound is contaminated. If there is no damage deep to the skin, then primary closure
can be performed.
Use intuition, some patients have much thicker skin than others and will require a larger suture to facilitate wound closure.
BODY AREA SIZE MATERIAL REMOVAL TIME
Face/Lip 6-0 Mono
Scalp 3-0, 4-0 Mono
Chest/Abdomen/Back 3-0, 4-0 Mono
Limbs 3-0 to 5-0 Mono
Hands 4-0 or 5-0 Mono
Nailbed 6-0 Braided, rapidly absorbable Absorbable
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Setup

This is a sterile procedure, and therefore the wound and surrounding skin must be prepared with antiseptic solution before
placing a drape around the sterile
during the procedure. Although you may not need a surgical gown, you must don gloves and take care not to touch any
external surfaces.
Wash the wound and debride the skin edges if ragged or dirty. If you are certain there is no deep tissue damage you may
proceed to close the skin.
Load your needle holder by placing the needle in the tip of the holder, two-thirds of the distance from the tip to the thread.
Plan the entry and exit of your suture on either side of the wound. The suture should lie perpendicularly across the wound
with equal depth and distance from the wound edge.
Load the needle between the apex of its curvature and two-thirds from the needle tip

Horizontal mattress suture

1. Gently lift the skin with the forceps and pierce the skin surface with the needle perpendicular (90°) to the skin at
approximately 4mm from the wound edge (if the wound is under tension a bigger needle bite may be required).
2. Supinate your wrist so that the needle passes through the dermis and rises out of the middle of the wound.
3. Use your forceps to hold the needle whilst you release your needle holder.
4. Re-grasp the needle in the same place with your needle holder.
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Gently lift the skin edge with the forceps and pierce the skin surface with the needle perpendicular to the skin
5. Lift the opposing skin edge gently with your forceps.
6. This time the needle has to travel perpendicularly through the dermis from inside to outside. Use the curvature of the needle
and supinate your wrist to move the needle through the skin. Equal needle bites of depth and distance from the wound should
be taken to allow wound edges to oppose equally and neatly.
7. Again, use your forceps to grasp the needle and pull it through the skin. You should continue to follow the curvature of the
needle as it travels through the skin, pulling the suture through as you go. You should now have a suture crossing
perpendicularly to the wound, approximately 4mm from the wound edge. If the wound is under tension, you can take a bigger
'bite' of skin either side, meaning you enter and exit the skin between 5-8mm from the wound edge.
Lift the opposing skin edge gently with your forceps
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8. Now re-load the needle facing the opposite direction (away from you). The aim is the throw another suture across the wound
8-10mm distal and parallel to you
your knot away from, and parallel to, the wound.
9. Again, you can remove your
with the forceps, and pierce the skin surface with the needle perpendicular to the skin.
10. Because your needle is loaded facing away from you, you will need to pronate your wrist so that the needle passes through
the dermis and rises out of the wound.
11. Use your forceps to hold the needle whilst you release with your needle holder.
12. Re-grasp the needle in the same place with your needle holder.
13. Lift the opposing skin edge gently with your forceps.
14. This time the needle needs to travel perpendicular through the dermis from inside to outside. Use the curvature of the
needle and pronate your wrist to move the needle through the skin back to where you started.
15. Again, use your forceps to grasp the needle and pull it through the skin. You should continue to follow the curvature of the
needle as it travels through the skin. Finally, pull the suture through.
Re-load the needle facing the opposite direction

Knot tie

1. Put down the forceps.
2. Pull the suture through so there is approximately 3cm of length on the opposing side.
3. Hold the suture in your non-dominant hand and the needle holder in your dominant hand.
4. Loop the suture away from you around the needle holder twice, then grasp the suture end with your needle holder. Pull the
needle holder towards you and push your non-dominant hand away to lay the
5. Let go of the suture with your needle holder but keep hold of it in your non-dominant hand.
6. Now loop the suture back towards you around the needle holder once and grasp the suture end with your needle holder.
Push the needle holder away from you and bring your non-dominant hand towards you to lay the second knot.
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7. Finally, loop the suture away from you around the needle holder once, then grasp the suture end with your needle holder.
Pull the needle holder towards you and push your non-dominant hand away to lay the
too tight or you risk crushing skin and causing tissue ischaemia. The knot will lie on one side of the wound because you have
both suture ends coming from the same side.
8. Now cut the suture between 5-6mm in length. If it is too short the knot will come undone. If it is too long, the suture material
will become trapped within other knots and they will come undone.
Loop the suture away from you around the needle holder twice

Wound care

Once you have completed suturing, you must ensure that you account for and dispose of your sharps immediately in a sharps
bin.
The wound should be washed and dried, then dressed appropriately. Dressings depend on the site of the body and
professional preference, below are some examples\:
Face\: Cover with steristrips and Micropore tape or provide chloramphenicol 1% ointment.
Limb\: Cover with a non-adhesive dressing such as Jelonet, Mepetel, or Sil
wound may be covered with an OpSite or a Mepore waterproof dressing.
Torso\: Cover with non-adhesive then Opsite or Mepore. If large you may consider gauze and Me

Follow-up

All wounds should be reviewed in 5 7 days and sutures removed (if non absorbable) as per the table above
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